Staffing Deficiencies Lead to Resident Neglect
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of ten out of thirteen residents, as evidenced by multiple resident interviews and observations. Residents reported excessive wait times for call light responses, with some waiting up to six hours. Confidential residents expressed distress over being left in soiled conditions, with one resident stating they were told to have a bowel movement in their brief due to staff unavailability. Observations confirmed that residents were left in unsanitary conditions, such as being in wet clothing or having soiled bedding, indicating a lack of timely assistance from staff. Additionally, documentation revealed inconsistencies in the provision of showers and bathing for residents. For instance, one resident's bathing record showed multiple instances of missed or undocumented showers over a period of several weeks. Interviews with residents further highlighted the inadequacy of staffing, with some residents stating they had to wash themselves due to missed showers. The facility's administration acknowledged the staffing deficiencies, confirming the inability to meet resident needs adequately.
Plan Of Correction
Social services reviewed the grievance log and found no unaddressed care concerns. Social services interviewed twenty alert and oriented residents, who at the time did not express any delay of care or overall care issues. Social services additionally walked the entire building performing visual audits to include any residents who are not alert and oriented to ensure timely care was provided. At this time, there are no active grievances related to delay in care due to staffing. Any residents who have a shower report that is identified as refusing and/or N/A identified, the assigned staff will have 1:1 education from the nurse educator/designee. To prevent future occurrences, nurses and aides will receive education by the Nurse Educator/designee on the importance of timely call bell response as well as the importance of showers/hygiene. The aides and nurses will also be educated by the Nurse Educator/designee on completion of ADLs, emptying urinals, making beds, etc. The Director of Nursing and/or designee will complete audits of call bells and shower/bathing records at random with 4 residents on each unit 2x a week for 1 month; then monthly thereafter with reporting through the Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.